20-102182-Building Permit ApplicationCITY OF"'�b�r�
Federal Way
PERMIT NUMBER
PERMIT APPLICATION
PERMIT CENTER + 33325 81h Avenue South + Federal Way, WA 98003-6325
253-835-2607 + FAX 253-835-2609 + permitcenter(ncityoffederalway.com
TARGET DATE
SITE ADDR>±SS
0� [ SW 3 ; AA '�502-3
SUITEMN1T #
PROJECT VALUATION
ZONING
ASSESSOR'S TAX/PA CEL #
TYPE OF PERMIT
IN BUILDING ❑ PLUMBING 0 MECHANICAL ❑ DEMOLITION ❑ ENGINEERING ❑ FIRE PRFVFNTION
NAME OF PROJECT
PA K <
PROJECT DESCRIPTION
U I C A EDOF— F—
Detailed description of work to
be included on this permit only
NAME }
LIN A S'b }{
PRIMARY PHONE
2 ii 3 --1 - 02.
PROPERTY OWNER
MAILING ADDRESS S
3 0 1 A\)- S.
E_
r,
CITY
STATE ZIP
o o (
NAME
PHONE
MAILING ADDRESS
E-MAIL
CONTRACTOR
CITY
STATE ZIP
FAX
WA STATE CONTRACTOR'S LICENSE # EXPIRATION DATE
URI #
NAME
o f� Art-
PRIMARY PHONE
206- -- I l c
APPLICANT
MAILING ADDRESS., b I s w 4 5
E-MAIL
JO ryr L" IC C 3 J U ✓I ICi,� ,
CITY
v��
STATE
v�
ZIP
�18b3
FAR
�fl6�z� - n8
PROJECT
PROJECT CONTACT
NAME
p f E1 K
PRIMARY PHONE
�3c
2 D b- -f [
MAILING ADDRESS 0 S l� 3�_ ��
�1
IS -MAIL
h I
(The individual to receive and
respond to all correspondence
CITY --
AZIP
TV�
FAX 26�-Z 6
concerning this application}
PROJECT FINANCING
NAME
❑ OWNER -FINANCED
When value is $5,000 or more
(RCW 19,27,095)
MAILING ADDRESS, CITY, STATE, ZIP
PHONE
I certify under penalty of perjury that I am the property owner or authorized agent of the property owner. I certify that to the best
of my knowledge, the information submitted in support of this permit application is true and correct. I certify that I will comply with
all applicable City of Federal Way regulations pertaining to the work authorised by the issuance of a permit. I understand that the
issuance of this permit does not remove the owner's responsibility for compliance with local, state, or federal laws regulating
construction or environmental laws.
I further agree to hold harmless the City of Federal Wag as to any claim (including costs, expenses, and attorneys' fees incurred in
the investigation and defense of such claim), which may be made by any person, including the undersigned, and filed against the city,
but only where such claim arises out of the reliance of the city, including its officers and employees, upon the accuracy of the
information supplied to the city as a p this application.
SIGNATURE: DATE
1'
PRINT NAME: _.� � PA It
Bulletin 4 t00 — February 19, 2020 Page 1 of 2 k:\Handouts\Permit Application